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Pluye, P., Grad, R.M., Leung, K.H., Bambrick, T., Marlow, B.A., Campbell, C., Bouthillier, F., Tabatabai, D., Dawes, M., Bartlett, G., & Rodriguez, C. (2009). Brief individual e-learning activities using information delivery and retrieval technology in a continuing medical education context: A literature review, an environmental scan, and interviews with experts. McGill Family Medicine Studies Online, 04: e01. http://mcgill-fammedstudies-recherchemedfam.pbwiki.com/MFMSO200904e01#. Archived by WebCite^® at http://www.webcitation.org/5fYlgZkDk

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Executive Summary

While high priority is given to the application of research-based knowledge in clinical practice, which is a component of knowledge translation, clinicians in primary care do not have the time to read and critically appraise original research. Delivering pre-appraised synopses of research articles to clinicians via email (information delivery technology or ‘push’ technology), and their retrieval by clinicians within databases (information retrieval technology or ‘pull’ technology) may help to solve this problem.

By way of illustration, members of the Canadian Medical Association (CMA) receive daily InfoPOEMs® delivered as email alerts (push). InfoPOEMs® stands for Information about Patient-Oriented Evidence that Matters. They are appraised synopses of peer-reviewed published research, selected for their validity and clinical relevance to primary care practitioners. These synopses may then be retrieved from a searchable database system, such as Essential Evidence Plus®, to assist with clinical decision-making (pull).

The present report aims to better understand the current status of individual e-learning activities that employ push and pull technology. To achieve this objective, we conducted a literature review, an environmental scan and interviews with an international panel of experts in continuing medical education (CME). Our questions were: (1) What are the information use and educational value associated with the usage of push and pull technology in accordance with the medical literature? (2) Under what conditions, can brief individual e-learning using push and pull technology be considered CME? ‘Brief’ refers to reading synopses of research papers, as opposed to conducting a structured review of the literature and performing critical appraisal of the selected studies.

Our literature review shows push and pull technology is increasingly used in routine medical practice, and results in physicians applying research-based knowledge in clinical decision-making. We examined this application using an educational perspective, and suggest using push and pull technology may trigger individual e-learning activity.

The environmental scan indicates the following. While there are policies to recognize literature reviews as CME activities (identification and selection of relevant studies, and critical appraisal of selected studies), (1) no specific policies exist to recognize brief individual e-learning activities using push technology, and (2) no specific policies exist to recognize brief individual e-learning activities using pull technology outside the USA. For each search within approved databases (pull), physicians may complete a brief questionnaire, and claim 0.5 ‘Prescribed Credit’ from the American Academy of Family Physicians (AAFP) or 0.5 ‘AMA PRA’ credits from the American Medical Association (AMA). In Canada, physicians may claim credit for reading research-based information on computer (push or pull), as for any reading activity (e.g., Mainpro-M2 credits issued by the College of Family Physicians of Canada - CFPC).

Interviews with experts support these findings from our literature review and environmental scan. The utilization of push and pull technology for individual e-learning CME can be part of a problem-based learning approach. For instance, retrieved information items might be used to address clinical problems encountered in clinical practice for a specific patient. Allocation of CME credits for brief individual e-learning activities could be based on self- assessment of cognitive processes (reflection), and as stated by the experts, allocation of CME credit in both the USA and Canada is also based on problem solving actions implemented in clinical practice (physicians being asked what they did with the information). The amount of time spent using technology is presently a criterion for allocating CME credit; however no consensus over the use of this criterion emerged from interviews with CME experts.

While the literature review suggests information retrieval for brief individual e-learning activities has educational value (pull), studies to document the educational value of information delivery (push) are just now emerging. Our prior research and the present review, environmental scan and expert panel interviews lead us to propose two options focusing on brief CME individual e-learning activities using push technology. We focus on push technology for two reasons: A specific policy and brief CME individual e-learning activities using pull technology are already implemented in the USA; and practice-based tools for tracking CME e-learning activities using pull technology have been developed in Canada in collaboration with major educational bodies.

Option 1: Transfer pull-related policy into a push context

Existing pull-related policy may be transferred to a push context where one hour spent on e-learning activities corresponds to one credit. Thus, the amount of time spent using push technology for e-learning activities can lead physicians to claim a fraction of CME credits. The amount of time may be tracked and reported to physicians for supporting their claim, or the average time spent to read and rate or comment on a research-based synopsis may be used as a metric for allocating credits. We propose a second option since there was no consensus on the amount of time spent using technology as a criterion for allocating CME credits.

Option 2: A new metric

When delivered on email, the number of opened, read and rated information items may be considered as an appropriate measure of brief individual e-learning CME activity (push technology). Delivered evidence-based information items can lead physicians to claim CME credits when they are read, and when reflective learning activities are documented, e.g., using the McGill ‘Information Assessment Method’ (relevance, cognitive impact, use for a specific patient and expected health benefits). In Canada, further CME activities can be suggested to the learner when information items are used for a specific patient, specifically via a link to one of the following tools when appropriate: Mini-Pearls® exercise (CFPC), ‘Le plan d’auto-gestion du dévelopement professionnel continu’ (Collège des médecins du Québec - CMQ), and ‘Personal Learning Projects’ (Royal College of Physicians and Surgeons of Canada - RCPSC). In other words, using push technology may reveal ‘unknown information needs’, and trigger the use of pull technology for patient-related problem-solving activities.

In conclusion, both of these options may act as a guide for physician self-assessment, and for CME accreditation or other CME policy development. At the time this report is written, the CFPC and the RCPSC have integrated ‘option 2’ into their policies and policy-making processes, respectively. Our work suggests more educational research is needed on issues concerning push and pull technology in clinical practice, individual reflective e-learning, and their potential outcomes (physician practice, organizational learning and health outcomes).

Acknowledgements

This work is supported by the Institute of Health Services and Policy Research, Canadian Institutes of Health Research. The authors gratefully acknowledge contributions of the expert panel and the six reviewers.